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1. Patients HI Claim No.            2. Start of Care Date             3. Certification Period                  4. Medical         5. Provider #
                                                                                                               Record #
                                                                      From:              To:

6. Patient’s Name and Address                                           7. Provider’s Name, Address and Telephone Number

8. Date of Birth:                             9. M       F

11. ICD-9-CM           Principal Diagnosis                  Date        10. Medications: Dose, frequency/Route (N)ew (C)hanged

12. ICD-9-CM           Surgical Procedures                  Date

13. ICD-9-CM           Other Pertinent Diagnoses            Date

14. DME and Supplies                                                    15. Safety Measures:

16. Nutritional Req.                                                    17. Allergies:

18.A Functional Limitations                                             18.B Activities Permitted
1. Amputation         5.Paralysis          9. Legally Blind   1. Complete Bedrest 6. Partial Weight Bearing                A Wheelchair
2. B/B Incont.        6. Endurance                             2. Bedrest BRP
                                             A Dyspnea w/ min. Ex.                     7.  Independent at home                B  Walker
3. Contracture        7.  Ambulation       B Other(specify)   3. Up as Tolerated 8. Crutches                               C No Restriction
4. Hearing            8. Speech                                4. Transfer bed/chair 9. Cane                                 D Other
                                                                 5. Exercises Prescribed
19. Mental Status: 1.Oriented       3. Forgetful      5.Disoriented         7.Agitated
                    2.Comatose      4 .Depressed      6.Lethargic           8.Other
20. Prognosis:      1.Poor          2.Guarded         3.Fair                4.Good           5.Excellent
21. Orders for Discipline and Treatments (SpecifyAmount/Frequency/Duration)

22. Goals/Rehabilitation Potential/Discharge Plans

23. Nurse’s Signature and Date                                                                    25. Date HHA Received Signed POT

24. Physician’s Name and Address                                        26. I certify that this patient is confined to his/her home and needs
                                                                        intermittent skilled nursing care, physical therapy and or speech therapy or
                                                                        continues to need occupational therapy. The patient is under my care and I
                                                                        have authorized the services on this plan of care and will periodically
                                                                        review the plan
27. Attending Physician’s Signature and Date Signed                     28. Anyone who misrepresents, falsifies, or conceals essential information
                                                                        required for payment of Federal funds may be subject to fine,
                                                                        imprisonment, or civil penalty under applicable Federal laws.